Pediatric Neurological History and Physical

Dr. Julie A. Griffith

Pediatric Neurology

120 Ross Valley Drive

San Rafael, CA 94901

(415) 925-1616

Fax (415) 259-4011

e-mail:

www.Mybrainhealth.org

Neurological History and Physical

Patient’s name: __________________________________Date of birth:______________________________________

Date of examination: ______________________________

Referring practitioner: __________________________

Address:______________________________City, State, Zip Code __________________________________________

Phone number (___) _______________

Mother’s name ________________________________Father’s name _______________________________________

Legal guardian’s name (if different than above) ___________________________________

How did you find out about us or who referred you to this practice? ____________________________________________

_______________________________________________________

Identification: ______________ (nickname, if has one) is a right/left handed/ambidextrous __________ grade

____________yr ______mo old boy/girl referred for evaluation of _______________________________________

__________________________________________________________________________________________________________________________________________________________________________

History of present illness:

Past medical history:

Pregnancy: medical problems during pregnancy: _______________________________

medications taken during pregnancy: _______________________________

tobacco, alcohol, cocaine, other drugs of abuse: _______________________

gestation _______wks, (full term is 40 wks) _________________________

Labor: ______hrs, artificial/spontaneous rupture of membranes

Delivery: ______birth wt, ______ cm head circumference

childbirth was vaginal /induced/ by C-section

meconium (stool in amniotic fluid) yes/ no

vertex (head down, face back), or face up (occiput posterior)/ breech

heart rate abnormalities during delivery Yes/No

Neonatal: Difficulties feeding/suck/swallow Yes/No

Colicky/irritable infant Yes/No

Past neurologic history:

Headaches Yes/No If yes, describe: ______________________________

Significant head trauma Yes/No If yes, loss of consciousness? vomiting? lethargy?

____________________________________________

Seizures Yes/No

Meningitis Yes/No

Developmental history:

Bowel training Completed Yes/No By what age

Bladder training Completed Yes/No By what age

Please give ages in months or years when these milestones were acquired (as best approximated):

Motor

Gross ventral push up ____, sit _____, stand ______, walk _____, run ____

runs alternating feet up stairs without holding rail _____, tricycle _____

bicycle without training wheels ______ ,

frequent falls/clumsiness ______________

Fine reaching ____, hand-to-hand ______, pincer _____, drawing _____

scissors ______. Quality of handwriting: _________

Language cooing _______, babbling ______, 1st word by ______mos/yrs,

2 wds together ( noun/verb) _______, # word vocabulary by 2 yrs ______,

age when clearly understood by strangers _____________, lisp ______

difficulties with drooling/handling secretions or in swallowing food

________________________________

Social good eye contact ___________, appreciates affection/hugs __________

understands social cues of interaction appropriate for age Yes/No _____

aggressive? (bite/kick/hit, getting into fights) ____________,

plays with children younger/same age/only much older or adults ________

Therapy received in past or currently getting:

Occupational ____ times/wk, ___hrs/session, by whom ________, where _______,

began _____________, issues now covering _____________________

Physical ____ times/wk, ___hrs/session, by whom ________, where _______,

began _____________, issues now covering _____________________

Speech ____ times/wk, ___hrs/session, by whom ________, where _______,

began _____________, issues now covering _____________________

Past medical history, Medical Problems:

1) ________________ Date onset __________ Date resolved___________ treatment __________

2) ________________ Date onset __________ Date resolved___________ treatment __________

3) ________________ Date onset __________ Date resolved___________ treatment __________

Hospitalizations: for what _______________________________, when ______________

__________________________________________________________

Surgeries: ______________________________________, when ______________

Medications: name of drug ______________, dosage (mg)________, # times/day ____

name of drug ______________, dosage (mg)________, # times/day ____

Allergies to medications: ____________________, what happened to body __________________

Review of systems:

Dermatologic: white, brown or red birthmarks _________________________________

Endocrine: heat or cold sensitive, hair thinning/falling out, dry skin _____________

ENT: ear aches, problems with hearing _______________________________

Genito: abnormal development of genitalia:_____________________________

precocious puberty or abnormal menses:_________________________

difficulty with erection or ejaculation: _________________________

any concern of sexual abuse: _________________________________

Gastrointestinal: difficulties with swallowing/appetite/eating problems _______________

failure to thrive/obesity ______________________________________

stomach upset, belly pains, blood in stools _______________________

Heme: easy bruising or bleeding after injury ___________________________

Immunologic: frequent infections (pneumonias, urinary tract infections, many

ear infections, sinusitis) _____________________________________

any risk of HIV? (blood transfusion, IV drug abuse in parents or

known exposure of parents?) _________________________________

sexually active ___________________________________________

Neuro: difficulties with attention _____, hyperactivity ____, impulsiveness__

balance/coordination problems ______________________________

conduct difficulties _______________________________________

excessive fatigue/taking naps during the day ____________________

muscle aching/cramping/twitching or fasciculating muscles,

muscle weakness________________________________________

oppositional/defiant symptoms________

sleeping difficulties _______________________________________

unusual spells or behavior not mentioned anywhere above _________

Oncologic: unexplained weight loss, failure to thrive, fatigue

Orthopedic: significant accidents or traumas, bone aches, frequent fractures,

scoliosis or abnormal back curvature _________________________

Psychiatric: emotionally labile, weepy, sad, depressed, unusual behavior

any concern of physical abuse ______________________________

Ophthalmologic: difficulty with vision or with eye movements ___________________

Urinary: urinary urgency, frequency or new incontinence, bedtime enuresis

Other: ________________________________________________________

Educational history: Difficulties now? Yes /No If yes, please complete the following:

Schools in chronologic order:

Name of school age difficulties type of help given name of teacher #stud / # teachers

____________ ____ ____________ ___________________ _____________ _____________

____________ ____ ____________ ___________________ _____________

Family history: (please ask each biologic parent, even grandparents)

Abnormal anatomy of any body parts ______________________________________________________

Autoimmune disorder (lupus, diabetes mellitus, colitis, rheumatoid arthritis, other ) __________________

Birthmarks (white, red, brown) ___________________________________________________________

Genetic syndromes ___________________________________________________________

Grey hair, prematurely by the 30’s ________________________________________________________

Headaches or migraines ________________________________________________________________

Head size, unusually large or small _______________________________________________________

Learning difficulties (held back in school a year, dyslexia, math problems) _________________________

Left-handedness or ambidexterity _________________________________________________________

Mental retardation _____________________________________________________________________

Miscarriages/stillbirths, sudden infant death syndrome ________________________________________

Neurologic disease (multiple sclerosis, other) ________________________________________________

Seizures _____________________________________________________________________________

Early stroke or heart attack (before or at 55 yrs of age) _________________________________________

other diseases that run in the family _______________________________________________________

Social history:

Biologic parents are married/ living together/divorced/separated. There are _____ children.

Child’s name age

__________ _____

Mother’s occupation: _________________________________

Father’s occupation: _________________________________

Significant psychologic stressors include _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physical examination: (for doctor to fill out):

HC ( ) ( %); Ht ( ) cm, ( %); wt ( kg), ( %)

lying BP HR standing BP HR

General: ________________________________________________________________

HEENT: _____ eyes, _________ ears, ______ palate, ________skull, ____ant font,

___sutures, _____skull shape, ____ teeth

CV: ___ S1, S2, __ murmurs, gallops or rubs; ___cranial bruits

abd: _____ liver; ____ spleen

GU: ____ Tanner

derm: ____ neurocutaneous stigmata; hair: quality, hairline, whorls; nails

vertebrae/sacrum ____

ext: ____

Neurologic: MSE: attention:

language: ___naming, ___repetition, ___diadochokinesis ___writing , ___reading,

memory: auditory, verbal : /3 encoding, /3 regist, /3 at 5 minutes

visual-wd, shape: /3, sequence, wd shape

affect:

level of motor activity:

abstraction:

clock:

construction:

cn: ___/20 OD; ___/20 OS; ___ optic nerve, ___retinae, II- XII ___

motor: /5 throughout drift

gait: spontaneous: _____, ____toe, ____heel

sensory: Romberg:

face UE LE

LT ____ _____ _____

pin ____ _____ _____

cold ____ _____ _____

Labs/studies:

Head MRI:

EEG:

Impression:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessment:

1)____________________________________________________________________________

2)____________________________________________________________________________

3)____________________________________________________________________________

Plan:

1)___________________________________________________________________________

2)___________________________________________________________________________

3)___________________________________________________________________________

4)___________________________________________________________________________

5)___________________________________________________________________________

6)___________________________________________________________________________

7)___________________________________________________________________________

Thank you for referring _______________________________ to my office. If you have any questions or suggestions,

please feel free to call me at (415) 925-1616.

Respectfully,

Julie A. Griffith, M.D., M.S., C.M.T.

Neurology

Julie A. Griffith, M.D., M.S., C.M.T.

120 Ross Valley Drive

San Rafael, CA 94901

Phone (415) 925-1616

Fax (415) 259-4011

CONFIDENTIAL SECTION:

Drug abuse:

Circle if prenatal use or use during pregnancy, current use, in the past use

alcohol use _________________________________

Amount of use, drink of choice, amount/day or week or month, number of

years drunk, ______________________________________________

Cocaine, heroine, marijuana, metamphetamines __________________________

Other drugs of abuse _____________________________________________

tobacco # of packs/day, # years smoked ______________________________

HIV testing: Testing: _______________

Treatment: ____________________________

Psychiatric: symptoms____________________________________________________________________________

____________________________________________________________________________

Diagnoses: ___________________________________________________________________________

___________________________________________________________________________

Treatment ___________________________________________________________________________

___________________________________________________________________________

Family history of :

HIV positivity: _______________________________________________________________________

Drug abuse: _______________________________________________________________________

_______________________________________________________________________

Psychiatric symptoms or diagnoses: _______________________________________________________

________________________________________________________________________

Pediatric Neuro H & P 03/21/07